<?php
/* @var $this FamilyHistoryController */
/* @var $model FamilyHistory */
/* @var $form CActiveForm */
?>

<div class="form">

<?php $form=$this->beginWidget('CActiveForm', array(
	'id'=>'family-history-form',
	'enableAjaxValidation'=>false,
)); ?>

	<p class="note">Fields with <span class="required">*</span> are required.</p>

	<?php echo $form->errorSummary($model); ?>

	<div class="column">
		<?php echo $form->labelEx($model,'blindness'); ?>
		<?php echo $form->dropDownList($model,'blindness', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'blindness'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU: '); ?>
		<?php echo $form->textField($model,'blindness_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'blindness_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'cataracts'); ?>
		<?php echo $form->dropDownList($model,'cataracts', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'cataracts'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'cataracts_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'cataracts_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Crossed Eyes'); ?>
		<?php echo $form->dropDownList($model,'crosseyes', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'crosseyes'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'croseyes_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'croseyes_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Glaucoma'); ?>
		<?php echo $form->dropDownList($model,'galucoma', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'galucoma'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'galucoma_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'galucoma_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'macular_degeneration'); ?>
		<?php echo $form->dropDownList($model,'macular_degeneration', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'macular_degeneration'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'macula_degenerationr_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'macula_degenerationr_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'retinal_disease'); ?>
		<?php echo $form->dropDownList($model,'retinal_disease', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'retinal_disease'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'retinal_disease_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'retinal_disease_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Arthritis'); ?>
		<?php echo $form->dropDownList($model,'arthiritis', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'arthiritis'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'arthiritis_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'arthiritis_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'cancer'); ?>
		<?php echo $form->dropDownList($model,'cancer', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'cancer'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'If yes, please specify: '); ?>
		<?php echo $form->textField($model,'cancer_specify',array('size'=>45,'maxlength'=>45)); ?>
		<?php echo $form->error($model,'cancer_specify'); ?>
	</div>
	
	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'cancer_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'cancer_relate'); ?>
	</div>
	<div class="column">
		<?php echo $form->labelEx($model,'diabetes'); ?>
		<?php echo $form->dropDownList($model,'diabetes', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'diabetes'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'diabetes_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'diabetes_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'heart_disease'); ?>
		<?php echo $form->dropDownList($model,'heart_disease', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'heart_disease'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'heart_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'heart_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'high_blood_pressure'); ?>
		<?php echo $form->dropDownList($model,'high_blood_pressure', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'high_blood_pressure'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'high_blood_pressure_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'high_blood_pressure_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Kidney Disease'); ?>
		<?php echo $form->dropDownList($model,'kidney', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'kidney'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'kidney_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'kidney_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'lupus'); ?>
		<?php echo $form->dropDownList($model,'lupus', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'lupus'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'lupus_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'lupus_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'thyroid'); ?>
		<?php echo $form->dropDownList($model,'thyroid', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'thyroid'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'thyroid_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'thyroid_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'others'); ?>
		<?php echo $form->dropDownList($model,'others', array('-' => '-','Yes'=>'Yes','No'=>'No')); ?>
		<?php echo $form->error($model,'others'); ?>
	</div>

	<div class="row">
		<?php echo $form->labelEx($model,'If yes, please specify: '); ?>
		<?php echo $form->textField($model,'others_specify',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'others_specify'); ?>
	</div>
	
	<div class="row">
		<?php echo $form->labelEx($model,'RELATIONSHIP TO YOU:'); ?>
		<?php echo $form->textField($model,'others_relate',array('size'=>60,'maxlength'=>100)); ?>
		<?php echo $form->error($model,'others_relate'); ?>
	</div>

	<div class="column">
		<?php echo $form->labelEx($model,'Patient Name'); ?>
		<?php echo $form->dropDownList($model,'personalinfo_id', CHtml::listData(

		PersonalInformation::model() ->findAll(), 'id','fname', 'lname'), array('prompt' => 'Select Patient')); ?>

		<?php echo $form->error($model,'personalinfo_id'); ?>
	</div>

	<div class="row buttons">
		<?php echo CHtml::submitButton($model->isNewRecord ? 'Create' : 'Save'); ?>
	</div>

<?php $this->endWidget(); ?>

</div><!-- form -->